Dr. Thomas Fishbein: Small Bowel Transplant Options - [Video Transcription]
- I never heard of a small bowel transplant. How long have they been around?
In the earlier mid 1990s, we just began a rebirth of the field of intestine transplantation which had been tried in animals and never been successful before then. At that time, we started to get the initial success. That is when I started getting involved in this field. Over the last decade, we have made improvements. So, in the last five years, we have routine long term survival when we do a survival and do an intestinal transplant in someone who has lost that organ function.
- What leads to a person needing a small bowel transplant?
There are a couple different classes of disease that lead patients to need a small bowel transplant. The most common would be short bowel syndrome. Short bowel syndrome is the case which patients lose the function of or a surgeon needs to resect and remove a portion of the small intestine. When more than half or two thirds of the intestine has been removed, the intestine can no longer function by absorbing enough nutrients, food, and liquids to maintain someone's nutritional state and their health. In that case, one can live on intra-venous feeding for a period of time. Ultimately, a small bowel transplant may be necessary. There are two other problems that lead patients to need small bowel transplants. One is disorders of motility of the small intestine. If you think of the intestine as a long garden hose with high pressure in it. The hose wiggles around and that motion of the wiggling around is done by the small bowel as well. It is called the small bowel's motility. In motility disorders, the small bowel just lays still like an empty sac. It doesn't wiggle and move the food through. This is another problem that can lead to a small intestine transplant. Finally, some patients have tumors. Tumors in the small intestine or around the blood vessels that bring the blood supply to the small intestine cannot be removed often unless the whole intestine can be removed with them.
- Why do you sometimes end up transplanting more than one organ?
You can imagine that heart, kidney, and liver transplants are very complex in themselves. When patients lose the function of their intestine and they live on intra-venous feeding or TPN for a period of time, they often go on to develop other end organ failures like liver failure or kidney failure. When those happen, patients often need their entire gastrointestinal tract replaced. This means doing a transplant of the liver as well as the intestine and sometimes even other organs such as the stomach, pancreas, large intestine of the colon, and kidneys. While someone who needs a small bowel transplant might require a single organ transplant of just the small bowel, they might require a six or seven organ transplant.
- What distinguishes Georgetown's small bowel transplant program from others?
For small bowel and multi-visceral transplants, I think the critical feature that distinguishes Georgetown from other centers is our degree of experience. We have evolved a team of healthcare professionals that work in the care of the patient who requires TPN, who work to try and avoid transplants by doing intestinal rehabilitation, or improve the function of the residual gut in a patient that has short bowel or intestinal failure to avoid a transplant. When all else fails, the same personnel are the same personnel in the small bowel transplant.
- How have these transplants gotten better in the past years?
Five or ten years ago, most of these children went on to diet in fact without having been referred to a transplant center. We like to get patients as we do from all over the United States very early in the first couple months of life. We are able to work on the function of their intestinal tract from very early on before they develop liver failure on the TPN. When we get patients in that sort of scenario, we have a much better chance of success in avoiding a transplant. Also when a patient needs a transplant, we have a long period of time to work with a family or other caregivers and get them prepared for a transplant.
- Tell me about the new pediatric transplant unit at GUH?
There is a great burden on families as you might imagine who have to travel across the country with their child and stay for sometimes months at a time in a big city of Washington D.C. Because of the needs of these families, we have developed an inpatient unit particularly for children, a pediatric transplant unit, which is really like none other in the country. In this unit, all the rooms are single rooms. The child when they are off critical care stays in the room with a parent who can live in. There are built in beds and facilities in the room so that a caregiver or parent can live in the room for extended periods of time until they are discharged from the hospital.
- What steps will I go through when I come to GUH for my transplant?
When you come to Georgetown for an evaluation for pediatric liver transplant, we typically do an inter-disciplinary evaluation. A nurse who understands liver diseases will meet with the family and do a lot of educational programs with regards to teaching about the possibility of transplant and immune suppression management after transplant. A social worker will also assess the family's situation and provide whatever help might be required to get through this sort of thing. It is often difficult when families have multiple other children and other demands of work and those sort of things. Additionally, the family will be evaluated and the child will be evaluated by a transplant surgeon for the technical details relating to the transplant.
- What are some of the breakthroughs for small bowel transplant that can benefit me?
Some of the reasons that it has improved is because we have learned how to use them in a wiser manner over time. The main lesson that we have learned is that less is more. We cut immune suppressive medications to very low levels very early on. Steroids are part of the protocol for patients receiving a transplant, but within in the first few months after receiving a transplant virtually all of our children are completely off any steroids. Another real breakthrough is the development of medications for immunosuppressant. While we used to have only one or two fairly toxic medications early in the days of the development of liver transplants, we now have a whole host of different types of medications, different doses, and different ways to administer them. Some are through an IV, some by pills, and some by liquid forms. They are much better tolerated in lower doses.
- I have heard about split liver transplants in the news. How do you do those?
If there is no cadaver organ in the period of time necessary or live donor, we may do other things like split liver transplants. This is a highly complex technical undertaking in which we take a cadaver organ from an adult and split off a small portion of that liver just like we would from a live donor. We take the small portion of the cadaver liver that is the right side and bring it back and transplant a baby with that. The other portion of the cadaver organ may go on and be transplanted to an adult patient.
- What are split liver transplants so rare?
There are not very many done nationally. There are only about 100 a year in the entire United States. It requires that we get a perfect cadaver organ. The organ has to be of perfect quality. The next most important factor is to have the degree of expertise and experience on the surgical team in order to go out and split the organ and then perform two simultaneous transplants. We have that here, but most liver transplants don't.
